'IS
CONTENTS
Introduction
1
PART I. EXAMINATION
1.
II
I
2
-
History and General Examination
5
History
5
Terminology
8
Physical Examination
9
Examination of Specific Systems
13
Skin
13
The Fingertip and Nailbed
13
Muscles
15
Nerves
35
Circulation
45
Anatomy of the Bones and Joints
47
PART II. COMMON CLINICAL PROBLEMS
3.
Lacerations
59
4.
Common Fractures and Dislocations
63
Intra-articular Fractures
67
M
,|
xvi CONTENTS
CONTENTS xvii\
Bennett's Fracture
Fifth CMC Fracture-Dislocation
Boxer's Fracture
Fracture of the Scaphoid
69
Undergrowth (Hypoplasia)
101
69
Congenital Constriction Band Syndrome
101
69
Generalized Skeletal Abnormalities *
71
Torn Ulnar Collateral Ligament of the
5.
71
Acquired Deformities
Swan-neck Deformity
Claw Hand
Dupuytren's Contracture
Rheumatoid Arthritis
Degenerative Arthritis
DeQuervain's Tenosynovitis
Trigger Thumb and Trigger Finger
Carpal Tunnel Syndrome
Cubital Tunnel Syndrome
Lateral Epicondylitis
6.
Congenital Anomalies
Failure of Formation of Parts
Failure of Differentiation (Separation) of
Parts
Duplication
Overgrowth (Gigantism]
« •
7.
Tumors
8.
Infection
Paronych ta
'
103
107
107
75
Felon
107
75
Purulent Tenosynovitis
107
78
Space Infections
109
78
Human Bite Infections
113
Mallet Finger
Boutonnidre Deformity
1
1
MCP Joint of the Thumb
102
(Madelung's Deformity) •
69
The MCP Joint Dislocation
78
Appendix 1: Key to Abbreviations Used in
81
the Text
81
Appendix 2: Anatomy — Summary
86
Appendix 3: Clinical Assessment
86
Recommendations
115
117
121
89
Sensibility
121
89
Strength
121
91
Motion
122
95
Vascular Status
127
97
Suggested Readings
129
98
Index
133
99
100
101
\
I N T R O D U C T I O N
This text is a core of information on the diagnostic history
and physical examination of the normal, diseased, or
injured hand. A method for thorough, systematic evaluation of the hand is presented so that with practice the
reader can develop a routine for accurate examination to
achieve a specific diagnosis.
A brief introduction to specific conditions of the hand
is given, followed by illustrations of the more common
disorders. A limited description of certain lacerations,
fractures, dislocations, and deformities is included.
Specific treatment of each diagnosis is not discussed.
The reader is referred to the standard texts and the current
literature of hand surgery for detailed descriptions of
treatment methods.
^
P A R T
1
E X A M I N A T I O N
A
1
HISTORY A N D
GENERAL
EXAMINATION
HISTORY
Before examining the hands, a detailed history of the
present problem should be obtained:
A. What are the patient's age, occupation, and pursuits?
WhicK_is ~tffe_dominanT~hand?y Has there been a
previous hand impairment or injury?
B. In trauma problems, the history should include the
following specific information:
1. When did the injury occur and how much time has
elapsed since the injury?
2. Where did the injury occur? Was it at work, home,
or play? Under what conditions was the environment—clean or dirty?
3. How did the injury happen? What was the exact
mechanism of the injury? (This helps to evaluate the
amount of crush, contamination, blood loss, and
level of injury to gliding parts.) What was the exact
posture of the hand at the time of injury?
^
HISTORY AND GENERAL EXAMINATION A
6 THE HAND
SURFACE ANATOMY
(Palmar surface)
JOINTS
Distal
,'' interphalangeal
(DIP)
_. Proximal
interphalangeal
(PIP)
Metacarpophalangeal
'(MCP)
MIDDLE
(or long]
INDEX
SEGMENTS
SMALL
Distal
phalanx
CREASES
Middle
phalanx
Distal
interphalangeal
Proximal
interphalangeal
Palmar digital
Distal palmar.
Proximal palmar
Thenar
Proximal
phalanx
Distal
phalanx
Proximal
phalanx
ULNAR
BORDER
RADIAL
BORDER
Wrist crease
Figure 1
Surface anatomy of the hand
DistoJ
phaJanges
Middle
phaJanges
Proximal
phalanges
Interphalangeal
\ =s^\
^Metacarpophalangealj
N
Carpometacarj)S]
rjbasilar joint)j
Metacarpals
Hamate
Pisi/orm
TriquetrymL.
Capitate
Lunate
_ Trapezoid^
f Trapezium?
Scaphoid
Figure 2
Skeleton of the hand and wrist
8 THE HAND
4. What previous treatment has been administered?
C. In nontrauma problems, particular emphasis should
be placed on:
1. When did the pain, sensory change, swelling, or
contracture begin? In what sequence? Are these
symptoms progressive?
2. How is function impaired in occupation, hobby, and
activities of daily living?
3. Are other joints or tendons in this or other extremities painful in a similar way?
4. What activities make the pain worse?
5. At what time of day or night is the pain worse?
D. A review of the past medical history and a review of
systems should be obtained as part of the complete
evaluation of the hand.
TERMINOLOGY
In order to avoid confusion it is important that standard
terminology for structures of the hand be used. The hand
and digits have a dorsal surface, a volar or palmar surface,
and radial and ulnar borders (Fig. 1). The palm is divided
into the thenar, mid-palm-, and hypothenar areasrThe
names of the digits are-the thumbrindex,-middle-(long),
r*ring, and", smaJMmgers. The thenar mass or eminence is
that muscular area on the palmar surface overlying the
thumb metacarpal. The hypothenar is that muscle mass
on the palmar surface overlying the small finger metacarpal. Each finger has three joints: the metacarpophalangeal (MCP), the proximal interphalangeal
(PIP), and the distal interphalangeal (DIP) joints (Fig. 2).
Note the location of the finger MCP joints in the palm near
the distal palmar crease, with the palmar-digital creases
and finger webs at the level of the middle third of the
proximal phalanges.
HISTORY AND GENERAL EXAMINATION 9
The thumb has an MCP and only one interphalangeal
(IP) joint. The carpometacarpal (CMC) joint of the thumb
is particularly important because of its mobility. There
are proximal, middle, and distal phalanges in the fingers
and only a proximal and a distal phalanx in the thumb.
The terminology used to describe the motion of the
joints is illustrated in Figure 3.
PHYSICAL EXAMINATION (see Ch. 2 for details)
The entire upper extremity should be exposed and
evaluated when the hand is examined. Assessment of
active shoulder motion, elbow motion, and pronation and
supination of the forearm is essential. Motion of these
joints is necessary for proper positioning of the hand for
function. Any discrepancy between active and passive
mobility should be noted.
When inspecting the hand, one should observe its color
to assess circulation as well as the radial and ulnar pulses.
The presence of swelling or edema should be noted as
well as any abnormal posture or position. Skin moisture,
localized tenderness, and sensibility must be evaluated.
After injury to the hand there is often secondary
stiffness and limited range of motion (ROM) of other
joints of the extremity as well as the part involved. The
range of both passive and active motion of the wrist, MCP
joint, and IP joints of each digit should be measured and
recorded. Grip and pinch strength should also be documented. The patient's ability to use the hand for simple
function should be evaluated.
Accurate recording of the findings of the examination
of the hand is most important. A simple sketch of the
hand with appropriate notations and measurements is
often very helpful.
^ a
HISTORY AND GENERAL EXAMINATION -11 \
10 THE HAND
FOREARM
Ulnar
deviation
Radial
j deviation
Opposing thumb
to finger
FINGER
Adduction
Hyperextension
Radial
abduction
Palmar
a=ion
Radial " ^ _
abduction
tension
Flexion
Retroposition
Figure 3
Terminology of hand and digit motion
Anteposition
fry-«-g
A
Y
I
12 THE HAND
Subsequent re-examination of the hand is just as
important as the initial examination and should be done
each time the patient returns for follow-up. Only by
making appropriate serial recordings during the followup period can the examiner know for certain whether or
not there is improvement in the patient's condition.
2
EXAMINATION OF
SPECIFIC
SYSTEMS
SKTN
The normal palmar skin is thick, tethered, irregularly
surfaced, and moist, providing for traction and durability.
Normal skin on the dorsum of the hand is thin and
mobile, permitting motion of the various joints. The
dorsum of the hand is the common site of edema, which
may limit flexion. The examiner should note the presence
or absence of swelling, wrinkles, color, moisture, scars,
skin lesions, and surface irregularities.
THE FINGERTIP AND NAILBED
The fingertip is defined as that portion of the digit distal
to the insertion of the extensor and flexor tendons into the
base of the distal phalanx (Fig. 4). The tuft of the distal
phalanx is well-padded by adipose tissue and covered by
highly innervated skin which is tethered to the distal
phalanx through a series of fibrosepta. The nailbed
complex on the dorsum of the fingertip is important in
providing additional stabilization of the palmar soft
tissues against compression and shear forces (Fig. 4). The
nailbed complex is also called the perionychium. The
13
EXAMINATION OF SPECIFIC SYSTEMS
14 THE HAND
distal skin of the nailbed complex is referred to as the
hyponychium. The cuticle or thin layer of skin bridging
the nail plate to the dorsal skin of the nail complex is
referred to as the eponychium. The nail plate arises from
a pocket called the nail fold. The floor of the nail plate or
nailbed is comprised of the proximal germinal matrix and
distal sterile matrix. The semicircular division between
these two areas is called the lunula.
FINGERTIP AND NAIL COMPLEX
Fingertip
Insertion extensor tendon
Nail fold
Nail plate ^f%P
/^
^
^
^
1
Insertion flexor tendon
Hyponychiunry^^ {{fy^y:
*®.
•B
FlbreEm^
Perionychium/nail complex
Sterile matrix
Lunula
MUSCLES
The muscles that power the hand may be divided into
extrinsic and intrinsic muscles. The extrinsic muscles
have their muscle bellies in the forearm and their tendon
insertions in the hand. They are further divided into
extrinsic flexor and extensor muscles. The flexors are on
the volar surface of the forearm and flex the wrist and
digits; the extensors are on the dorsum of the forearm and
extend the wrist and digits.
The intrinsic muscles have their origins and insertions
within the hand.
These muscles should be systematically evaluatedrAsk
the "patient t6~"n£akeL aJ^"J^ind -< 's1xaighten. pu£]yj5ur
fingers"^ this gives the examiner a general idea of the
active ROM of the digits. However, it is necessary to
examine each muscle group specifically.
Specific extrinsic muscle testing
Extrinsic flexor muscles
figure 4
The fingertip and nail complex
The function of the flexor pollicis longus (FPL) muscle,
whose tendon inserts on the volar base of the distal
/
16 THE HAND
EXAMINATION OF SPECIFIC SYSTEMS 17
phalanx of the thumb, can be ^ ^ * Z * % * * &
patient to "bend the tip of your thumb (Fig. 5). The
muscle strength is tested against resistance supplied by
^T^Tdigitorum
profundus (FDP) can brteatod by
asking the patient to "bend the tip of your finger (Fig. 6).
The PL? joint is stabilized in extension by the examiner as
the distal joint is actively flexed. As each finger is
examined, the muscle is tested against resis ance.
Z h flexor digitorum superficialis (FDS) is individually
tested by asking the patient to "bend yourfinger at the
m ddle joint" (Fig. ^ T h ^ W ^
K S u s
in extension by tHS. examiner so as to block profundus
S u c t i o n (The profundus tendons of the ulnar three djats
S S f c L n S n muscle belly, and thus independent
flexion of any finger with the other digxts restrained in
extension requires intact FDS musculotendinous functionTto that finger-) The procedure is repeated for each
^The flexor carpi ulnaris (FCU), flexor carpi radialis
(FCR), and palmaris longus (PL) are evaluated by asking
£ e patient to flex his wrist while the examiner palpates
the tendons of these muscles. The FCU insert. m t e t h e
pisiform and the FCR into the volar aspect
<*****»*
metacarpal. The PL inserts into the palmar fascia. The PL
S i be noted to lie between the FCR radially and FCU Z a r l y on the volar surface of the wrist dunng this
maneuver, especially if the thumb is simultaneously
opposed to the small finger.
Extrinsic extensor
Figure 5
Testing for FPL musculotendinous function
muscles
The extrinsic extensor muscle bellies of the hand overlie
the dorsum of the forearm, and their tendons pass over the
- /
IS THE HAND
EXAMINATION OF SPECIFIC SYSTEMS 19
Figure 6
TestingforFDP musculotendinous
Amotion
Figure 7
Testing FDS musculotendinous function
V
Ii
r ^
20 THE HAND
Figure 8
Arrangement of extensor tendons at the wrist into six compartments:
dorsal and cross-sectional views
^
»
EXAMINATION OF SPECIFIC SYSTEMS 21
Testing for
Figure 9
EPB and APL musculotendinous function
22 THE HAND
EXAMINATION OF SPECIFIC SYSTEMS 23
^
dorsum of the wrist to insert in the hand (Fig. 8) They are
arranged in six tendon compartments over the dorsum of
tiie wrist A systematic examination of the tendons
passing through each compartment is done.
«f fJ™ f i *f d o f s ' 5 1 ^ i s t compartment contains the tendons
of the abductor pollicis longus (APL), which inserts at the
dorsal base of the thumb metacarpal, and the extensor
polhas brevis QPB), which inserts at the dorsal base of the
proximal phalanx of the thumb. These-are-evaluatriby
S a D S , t ^ p a l f e f i r t 0 " b r i n 8 y o u r t h u m b 6utJp,thTsTde"
Fig. 9). The examiner canpllpate'the'taut tendons over
the radial side of the wrist going to the thumb.
Tnersecofld dorsaDwrist compartment contains the
tendons of the extensor carpi radialis longus (ECRL) and
the extensor carpi radialis brevis (ECRB) muscles (Fig 10)
They insert at the dorsal base of the index and middle
metacarpals, respectively. These are evaluated by asking
s L ^ T h 0 exa
" ^1 a fiSt a n d b r i n g y™ ™ * back
Ih^A
™ ™ can give resistance and palpate
the tendons over the dorsoradial aspect of the wrist
In the ^third-dorsal ^mst compartment, the extensor
polhas longus (EPL) tendon passes around Lister's tubercle of the radius and inserts on the dorsal base of the distal
phalanx of the, fcumb. This..murcle is evaluated-by
placing the hand flat on the table and having the-patient
lift only the thumb off the surface (Fig. i i )
Tteiouia..fasal^mst
compartment contains the
endons that are the MCP joint extensors of the fingers
(Figs. 8 and 12). The extensor digtirum communis (EDO
and the extensor mdicis proprius (EIP) muscle tendons are
fintUS > S i ^ u n g * e P a t i e n t t 0 " ^ a i g h t e n your
fingers and by observing MCP joint extension.
The EIP tendon can be isolated on examination by
asking the patient to "bring your pointing finger out
Figure 10
Testing for ECRL and ECRB musculotendinous function
,Ai
24 THE HAND
EXAMINATION OF SPECIFIC SYSTEMS 25
straight, with the other fingers bent in a fist." The EIP is
acting alone to extend the index finger MCP joint (Fig. 12).
The fifth dorsal wrist compartment contains the tendon
of the extensor digiti minimi (EDM) (Fig. 12). This is
evaluated by asking the patient to "straighten out your
small finger with your other fingers bent in a fist." This
extends the MCP joint of the small finger. The EDM is
acting alone to extend the small finger.
The sixth dorsal wrist compartment contains the tendon
of the extensor carpi ulnaris (ECU), which inserts at the
dorsal base of the fifth metacarpal (Fig. 13). This is
evaluated by asking the patient to "pull your hand up and
out to the side." The taut tendon can be palpated over the
ulnar side of the wrist just distal to the ulnar head.
Extrinsic extensor tightness. The extensor tendons can
become adherent over the dorsum of the hand or wrist,
limiting finger flexion. This can be tested by maintaining
the wrist in neutral and passively extending the MCP joint
and flexing the PIP joint. Normally, the PIP joint should
flex. The test is then repeated with the MCP joint
passively flexed. If the PIP joint will passively flex when
the MCP joint is extended,_but will not flex readily with
the MCP joint flexed, the adherent extrinsic extensors are
"cHeckreining the simultaneous flexion of finger MCP and
PIP joints. This is called "extrinsic extensor tightness."
Intrinsic muscles
Figure 11
TestingforEPL musculotendinous function
The intrinsic muscles of the hand are those that have their
origins and insertions within the hand. These are the
thenar muscle group, adductor pollicis (AdP), lumbrical,
and interosseous muscles and the hypothenar muscle
group.
A,
26 THE HAND
EXAMINATION OF SPECIFIC SYSTEMS 27
Figure 12
Toting
for.E^c;E^an7^
'musc^oteadiffiys3uHrtiSn
Figure 13
Testing for ECU musculotendinous function
/
28 THE HAND
EXAMINATION OF SPECIFIC SYSTEMS 29
Figure 14
Testingforthumb opposition
Figure 15 (A&B)
Fromerit's^sigriMs positive in hand B
'V]
EXAMINATION OF SPECIFIC SYSTEMS 31
The thenar muscles
The thenar muscles are the muscles covering the thumb
metacarpal. They are the abductor pollicis brevis fAPB),
opponens pollicis (OP), and flexor pollicis brevis (FPB).
These muscles pronate or oppose the thumb (see Fig. 3)
and can be evaluated by asking the patient to "touch the
thumb and small fingertips together so that the nails are
parallel" (Fig. 14). They can also be tested by asking the
patient to place the dorsum of the hand flat on the table
and raise the thumb up straight to form a 90° angle with
the palm (see Fig. 3). At that time it is most important to
palpate the thenar muscles to note if they contract. It is
helpful to examine and compare the contralateral hand in
a similar way to detect slight variations in muscle mass
and function. The thenar muscles are usually innervated
by the motor branch of the median nerve. In some
patients, however, the thenar muscles may be partially
innervated by the ulnar nerve.
The adductor pollicis muscle
Thumb adduction is separately tested by having the
patient forcibly~holda_piece of paper .Bejwe_enthejthumb
and radial side of the index proximal phalanx (Fig. 15).
The muscle that-powers'this motion is the AdP, which is
innervated by the ulnar nerve. When thisjnuscle is weak
or nonfunctioning the thumb IP joint flexes with this
maneuver (Froment's sign). In this evaluation the two
hands must be compared.
The interosseous and lumbrical
muscles
The interosseous and lumbrical muscles act on the fingers
to flex the MCP joints and extend „the IP joints. The
interosseous muscles also abduct and adduct the fingers.
The interosseous muscles, which lie on either side of the
finger metacarpals, are innervated by the ulnar nerve.
They can be evaluated by asking the patient to "spread
your fingers apart" while the examiner palpates the first
dorsal interosseous to see if it contracts. In another test,
with the hand flat on a table, the patient is asked to elevate
(i.e., hyperextend the MCP joint with the IP joints
straight) the middle finger and radially and ulnarly
deviate it (Fig. 16). (This eliminates the extrinsic extensors, which some patients can use to mimic interossei
finger abduction-adduction.)
The hypothenar
„
di
muscles
The hypothenar muscles —abductor digiti minimi (ADM),
flexor digiti minimi (FDM), and opponens digiti minimi
(ODM) —are evaluated as a group by asking the patient to
"bring the small finger away from the other fingers" (Fig.
17). This muscle mass is palpated at that time, and a
dimpling of the hypothenar skin is noted.
Intrinsic muscle tightness. To test for finger intrinsic
muscle tightness the MCP joint of the finger is held in
extension (0° neutral position) while the PIP joint is
passively flexed by the examiner (Fig. 18). The MCP joint
is then flexed and the PIP joint is passively flexed in the
same manner as before. If the PIP joint can be passively
flexed with the MCP joint in flexion, but cannot be fully
flexed when the MCP joint is extended, there is tightness
of the intrinsic muscles. This is called "intrinsic tightness."
7T
7
.
32 THE HAND
EXAMINATION OF SPECIFIC SYSTEMS 33
Figure 16
Testing for interosseous muscle function
Figure 17
Testing for hypothenar muscle function
^
EXAMINATION OF SPECIFIC SYSTEMS 35
NERVES
The hand is innervated by the median, ulnar, and radial
nerves. Each of the three major nerves passes through a
muscle in the forearm and each passes points of potential
entrapment. All three nerves are involved in control of the
wrist, fingers, and thumb.
The median nerve
The median nerve enters the forearm through the pronator teres muscle and innervates the following muscles:
pronator teres, FCR, PL, FDS, radial part of the-FDFr-FPL1.
airiH pr^natm- q n a H ^ n s (Fig. 19). The branch of the
median nerve that innervates the latter three muscles is
referred to as foe aniBriar.internssp.oiis pgfve! The median
nerve travels distally through the forearm between the
FDS and FDP muscles. It enters the hand through the
carpal tunnel accompanied by the nine extrinsic flexor
tendons of the digits. The thenar motor branch innervates
the APB, the superficial belly of the FPB (variably so), and
the OP. The common digital branches innervate the
lumbrical muscles to the index and long fingers. The
nerve then continues through the palm as sensory
branches (described below).
The ulnar nerve
Figure 18
Intrinsic muscle tightness
The ulnar nerve enters the forearm from the posterior to
the medial epicondyle of the humerus and passes between
EXAMINATION OF SPECIFIC SYSTEMS 37
36 THE HAND
the two heads of the FCU (Fig. 20). It innervates the
following muscles in the forearm: the FCU and the ulnar
part of the FDP (usually to the ring and small fingers,
occasionally to the long finger). It enters the hand at the
wrist accompanied by the ulnar artery through a tunnel
radial to the pisiform bone, ulnar to the hook of the
hamate, volar to the deep transverse carpal ligament, and
dorsal to the volar carpal ligament (Fig. 21). Tjiis tunnel
is known as the uhiarjurmelor Guyon's canal. The ulnar
nerve innervates the hypothenar muscles (the ADM,
FDM, ODM), the seven interosseous muscles, the lumbrical muscles to the ring.and small fingers, and the AdP.
It may innervate part or all of the FPB.
~t
MEDIAN AND ANTERIOR
INTEROSSEOUS NERVES
Pronator teres
Flexor carpi radialis
Palmaris longus
Flexor digitorum super/iciali!
Flexor digitorum profundus
Flexor pollicis longus
Abductor pollicis brevis
Flexor pollicis brevis
Opponens pollicis
Index lumbrical
Middle lumbrical
Prontator quadratus
The radial nerve
The radial nerve innervates me"tfic.eps',.^c6Tleus;'brac£joradialisTiand ECRL muscles above the elbow and ECRB
as the nerve enters the forearm (Fig. 22). It passes through
the supinator muscle to innervate the following muscles
in the forearm: supinator, EDC, EDM, ECU, APL, EPL,
EPB, and EIP. Thus its important motor function is to ^
innervate the muscles irrthe forearm that extend the wrist
and MCP joints and tharabduct and extend the thumb. No
intrinsic muscles in the hand are innervated by the radial
nerve.
Sensory branches of the nerves
Pro/undus muscle is also supplied by ulnar
nerve (see text)
I
Figure 19
Muscles innervated by the median and anterior interosseous nerves in
the forearm and hand
E
L
As it leaves the carpal tunnel, the median nerve divides
into common sensory branches, which subsequently
divide and innervate the palmar surface of the thumb, the
index and middle fingers, and the radial side of the ring
BXM^oNOFsrecmcsvsT*^
38 THE HAND
ULNAR NERVE
Flexor carpi ulnaris
Flexor digitorum
pro/undus
Adductor pollicis
Deep head of
Flexor pollicis brevis
Palmaris brevis
Abductor
Opponens Digit minimi
Flexor
Little lumbrical
Ring lumbrical
Interossei
* Pro/undus muscle is also supplied by
median nerve (see text)
Figure 20
Muscles innervated by the ulnar nerve in the forearm and hand
fcL
Ulnar
Uln ar
tunnel at wrist (Guyon's canal) contains
CT, carpal tunnel
Figure 21
artery and nerve;
EXAMINATION OF SPECIFIC SYSTEMS 41
40 THE HAND
RADIAL NERVE
Triceps, long head _
Triceps, lateral head
Brachioradialis
Extensor carpi radialis longus
Extensor carpi radialis brevis — r I
Anconeus
Supinator
'I
'
Extensor digitorum communis
Extensor digiti minimi
Extensor carpi ulnaris ____^_
Abductor pollicis longus
,
Extensor pollicis longus
Extensor pollicis brevis
Extensor indicis proprius
Figure 22
Muscles innervated by the radial nerve in the forearm and hand
finger (Fig. 23). Dorsal digital branches arise from the
digital branches to innervate distal to the PIP joint, the
dorsal aspect of the index and middle fingers, and the
radial half of the ring finger. The median nerve also
innervates the volar wrist capsule by the terminal branch
of the anterior interosseous nerve.
The ulnar nerve divides distal to the hook of the hamate
into digital branches and innervateTthe smallTinger and
^^e-ulnar-fatdf^f-the^uiglinger (Fig. 23). The dorsal
cutaneous branch oi the ulnar nerve enters the dorsal
aspect of the hand over the small and ring metacarpals,
the dorsum of the small finger, and dorso-ulnar half of the
ring finger.
The radial nerve supplies sensibility to the radialthree
quarters of
quarters
m the
mo dorsum
u v . — of the hand and the dorsum of the
""thumb
dorsum
thumb (Fig.
(Fig. 23).
23). It
It also
also supplies
supplies sensibility
sensibility to
to the
uie uwcu...
-*t,
-.
j
iAA\
fingers
and
the
radial
half
nA
m
e
oftheindex and middle fingers and the radial half of
of the
the
ring finger as far distally as the PIP joint of each. It also
innervates the dorsal wrist capsule by the terminal
branch of the posterior interosseous nerve.
Anatomic variation
Anatomic variation should be considered in all cases
where there has been an injury to a major nerve trunk. For
example, there can be variations in the distribution of the
ulnar and median nerves in the hand. The entire ring
finger and ulnar side of the long finger may be innervated
by the ulnar nerve, or the entire ring finger may be
innervated by the median nerve. The palmar aspect of the
thumb may be innervated by the radial nerve. The lateral
antebrachial cutaneous nerve frequently overlaps the
radial sensory nerve.
42
THE HAND
EXAMINATION OF SPECIFIC SYSTEMS 43
Sensibility
Sensibility is one of the most important functions of the
hand. The insensible hand is poorly used even when the
tendons and joints are normal.
Normal skin should be slightly moist. Nerve dysfuncj
tion causes-loss of sympathetic innervation-in-the-area of
distribution,._and the sknrbecdmes'drvrThis isof clinical
help in evaluating nerve dysfunction. Testing the finger
with a sharp-pointed object, such as a pin, or thermal
testing is not as critical and helpful as to test it for tactile
gnosis by the moving and static two-point light touch
djscrimination test {2FD). In this test the hand is positioned at rest on a flat firm surface and the patient closes
his eyes. A device that measures innervation density,
such as the Disk-Criminator or something as simple as a
bent paper clip (Fig. 24) is used by beginning at a 6-mm
distance between the prongs and proceeding higher or
lower to determine the critical distance at which the
patient indicates he can distinguish two points from one.
An abnormal vahifefeE mm"static o r > 3 mm moving 2PD)
indicates axonal loss and is the sensory system equivalent
of wasting or atrophy in the motor system. This will occur
with all nerve division and severe nerve compression.
Vibratory perception is also lost with nerve division. With
a mild or moderate degree of nerve compression, 2PD is
preserved but sensory threshold changes, such as diminished perception of tuning fork stimulation and abnormal
cutaneous pressure threshold (Semmes-Weinstein monofilament testing), occur.
K
Figure 23
-tributionof m a i o r n e r v e s .
enervating the hand forsensory function
D
I
I n evaluating" children for-traumatic nerve injuries,1 it
may not be possible or practicjdJtojjgrfoim^PD test. In
this situation, the use of the<^mmersion test^may be of
benefit. The innervated glabrous skin of the hand will
wrinkle on immersion in water for 5 to 10 minutes.
44 THE HAND
EXAMINATION OF SPECIFIC SYSTEMS 45
Failure of the skin to wrinkle should raise the suspicion
of an underlying nerve injury.
CIRCULATION
The radial and ulnar arteries supply the hand with blood.
There is an arterial arch system that gives the hand a
generous collateral blood supply (Fig. 25).
The circulation of the hand is evaluated by noting the
color of the skin and fingernails as well as the blanching
and flush of the nailbed. The Allen test, used to determine
patency of the arteries supplying the hand, is done as
follows (Fig. 25):
Figure 24
W p o t o
domination testing
1. Compress the radial and ulnar arteries at the wrist.
2. Have the patient make a fist, open and close it
several times to exsanguinate the hand, and then
open the hand again into a relaxed position (avoid
hyperextension at this point, as it will maintain
blanching).
3. Release the radial artery only. If the palm and all five
digits fill with blood, then the radial artery is patent,
with good collateral flow into the ulnar artery
system.
4. Repeat steps 1 and 2.
5. Release the ulnar artery only. If the entire hand
flushes, then the ulnar artery is patent, with good
flow into the radial system.
6. Normal fillinfi-time for the hand through either
artery is "usually under. 5 seconds': A distinct difference in filling-time may suggest the dominance of
one artery in providing circulation to the hand.
V
\/_
EXAMINATION OF SPECIFIC SYSTEMS 47
The Allen test can also be carried out on a single digit
by expressing the blood out of the digit and occluding
both digital arteries and then releasing the radial digital
artery and noting the filling of the digit. The same
procedure is carried out on the ulnar digital artery. This
will help to evaluate the patency of each digital vessel to
that finger.
Another means of evaluating the arterial circulation of
the hand is the Doppler probe. This device is readily
available in most emergency rooms. The device can be
used to confirm the presence of pulsatile flow and to map
out the course of arteries through the hand.
ANATOMY O F THE BONES AND JOINTS
The skeleton of the hand consists of 27 bones, divided
into three groups: the carpus, the metacarpal bones, and
the phalanges (see Fig. 2).
The carpus
Figure 25
Allen test for arterial patency
The eight carpal bones are divided into two rows. Those
in the proximal row, beginning from the radial side, are
the scaphoid-, lunate, tiiquetaim,_andpisiform. Those in
the distal row are the trapeziurn, .trapezoid", capitate, and
hamate. Much of the surface of the carpal bones is
covered with cartilage, with roughened areas dorsally and
volarly for ligamentous attachments and for entry of the
vascular supply to the bone.
Wrist flexion and extension as well as radial and ulnar
deviation result from radiocarpal and intercarpal motion,
whereas pronation and supination occur through the
proximal and distal radioulnar joints.
A
48
THE HAND
EXAMINATION OF SPECIFIC SYSTEMS 49
Figure 26
^ m a r view of st abi li2ingliganj(
^oftheradiocaxpaj,-^
The versatile ROM of the wrist and its stability are
provided by a well-developed system of ligaments interconnecting the carpus and radius. These are most highly
developed on the palmar aspect of the wrist. The important ligaments stabilizing the radial aspect of the carpus
are the scapholunate interosseous ligament, radioscaphocapitate ligament, and radioscapholunate ligament
(Fig. 26). On the ulnar side of the wrist, the primary
stabilizer of the radioulnar joint is the triangular fibrocartilage, which originates from the dorso-ulnar corner of
the distal radius and inserts at the base of the ulnar styloid
(Fig. 27). The triangular fibrocartilage together with
ulnolunate ligament and the ulnar collateral ligament
comprise the ulnocarpal complex, which stabilizes the
ulnar aspect of the carpus.
A number of clinical tests can be used to evaluate the
stability of the wrist. The piano key test evaluates the
distal radioulnar joint. With one hand, firmly stabilize the
distal radius; with the other hand, grasp the head of the
ulna between the thumb and index fingers. Evaluate the
freedom of motion in an anteroposterior plane as well as
pain and crepitance. The scaphoid shift maneuver is
performed by placing the examiner's thumb over the
palmar aspect of the distal pole of the scaphoid. A
constant pressure is maintained with the examining
thumb as the wrist is moved from a position of extension,
ulnar deviation to flexion, radial deviation, and back
again. The presence of dorsal wrist pain or a clunk
suggests possible instability of the scapholunate ligament. The lunotriquetral shear maneuver involves stabilizing the lunate between the thumb and index finger of
one hand and the triquetrum between the thumb and
index finger of the other hand. A shear stress is then
created in an anteroposterior plane between these two
bones. Discomfort in this area suggests the possibility of
EXAMINATION OF SPECIFIC SYSTEMS 51
injury to the lunotriquetral interosseous ligament. In
performing all of these manuevers, it is important to
repeat the test on the uninjured, opposite wrist to provide
a basis for comparison of the patient's symptoms.
It is important to emphasize that the hand is not flat.
It is based on a system of skeletal arches which must be
maintained to preserve hand function (Fig. 28).
Fixed and mobile units
The metacarpals of the index and long fingers are firmly
attached to the rigidly interconnected distal carpal row to
form the "fixed" unit of the hand. From this are suspended
the "mobile or adaptive" components of the h a n d — t h e
thumb, the entire ring and small rays (including metacarpals), and the phalanges of the index and long fingers.
The longitudinal arch is apparent in the lateral projection and is formed by the metacarpals and phalanges.
There are two transverse arches: the proximal arch at the
distal carpus and the distal arch at the metacarpal heads.
The- thumb Tnetararpal artipiilates-withthetrapeziiim.
forming the unique basilar idinfTwhiclTallows -for a wide
latitude of thumb motion (Figs. 3 and 29).
The MCP and IP joints of the fingers are stabilized on
both sides by collateral ligaments and anteriorly- b y a;
palrnar;fibrocarfilaginouC"volar" plate (Fig..30).The digital flexor tendons lie just anterior to-these"plates. The
configuration of the metacarpal'heads causes their collateral ligaments to be slack in extension, permitting
abduction, adduction, and circumduction. In flexion,
however, MCP collateral ligaments become taut, providing stability to the joint.
Articular configuration of the IP joints and the geometry of the collateral ligaments do not allow significant
Figure 27
Stabilizing]^
^ntsoftheulnocazpali,joint
U i \
.A
1
i
EXAMINATION OF SPECIFIC SYSTEMS 53
Figure 2a
^ches of the hand
M
Figure 29
Basilar joint of the thumb
[
r?
54
THE HAND
EXAMINATION OF SPECIFIC SYSTEMS .55
Figure 30
Collateral li gam ,
' - ^ v o l a r p l ^ ^ ^ ^ . ^
figure 31
Pulleys of the digital flexor sheath; A, annular pulleys;
C, cruciate pulleys
56 THE HAND
mediolateral motion in extension or in flexion. The MCP'
joint of the thumb is more like the hinged IP joints than
the freely movable MCP joints of the fingers.
At the level of the MCP joint, the flexor tendons of the
digits enter a fibro-osseous tunnel referred toas the flexor
sheath.. At specific sites, trie stieath is thickened by
arinular fibers called pulleys (Fig. 31). The function-otthe
flexor sheath is to stabilize the tendons closely against the
palmar surface of the phalanges, facilitate efficient excursion of the tendons, and provide for tendon nutrition.
In the.fingers,-the-A2 and-A4-pulleys-are mo'sUmportant
for maintaining .the integrity of finger flexion. Without
these two pulleys, the fingertip cannot be brought to the
distal palmar flexion crease with normal tendor excursion. The flexor tendons and inner wall of the sheath are
lined with a tissue called tenosynovium. This tissue is
important in minimizing the friction of tendon excursion
as well as in providing Tendon nutrition through the
process of diffusion.
A
P A R T "
2
_
,
S
^
5
S
a
P R O B L E M S
_
N
,
C
A
L
3
LACERATIONS
One should develop a routine for examining the patient
with a lacerated forearm or hand so that nerve and tendon
injuries will not be overlooked. The patient who presents
with a bleeding laceration of the hand should be asked to
lie down. The hand is elevated, a sterile dressing is used
to cover the wound, and gentle direct pressure is applied.
The bleeding will usually stop within a few minutes. The
practice of "clamping a bleeder" in a lacerated hand
should be avoided. Previously undamaged vital structures, such as nerve or tendon, may be inadvertently
crushed and irrevocably damaged in an unnecessary
attempt to clamp a blood vessel.
There is a tendency on the part of inexperienced
physicians to look into the wound and see if nerves or
tendons have been cut. However, much more can be
learned on the initial examination by covering the wound
and performing a gentle, systematic examination of the
forearm and hand distal to the injury (Fig. 32). Each flexor
tendon must be tested separately for function, and it is
important to test IP function against gentle resistance. A
partially cut tendon may be able to flex the finger, but it
will not be able to do„so against resistanqe without
causing pain.
59
I
60
THE HAND
Figure 32
lamination of the lacerated hand
Figure 33
Laceration of EDC over MCP joint {i.e., distal to juncturae tendinae)
62 THE HAND
The position of the unsupported fingers should be
noted. When the flexor tendon is completely severed, the
unsupported finger restsjn extension (Fig. 32); when the
extrinsic extensor tendon is completely severed, the
im supported finger rests in flexion (Fig. 33). A careful
distal sensory examination is then done. In the emergency room setting, especially with a frightened child, far
more can be learned about the presence or absence of
sensation using a light touch with a wisp of cotton than
by testing sharp/dull with a pin. Only after the hand has
been completely assessed by the examining physician
should any anesthetic be used.
In lacerations of the dorsal aspect of the MCP joint of
the finger, a severed EDC will preclude active extension
of thg_MCP jnint (Fig 33).
Note that the intact intrinsic muscles will actively
extend the IP joints in the absence of extrinsic extensor
tendon function, just as the intact intrinsic muscles will
actively flex the MCP joint in the absence of extrinsic
flexor tendon function.
A laceration over the MCP joint (knuckles) should alert
the examiner to the possibility ol its naving resulted from
a hjnnan^bite__or a blow apainst someAeeth. These
laceTanOhiTare oT special importance because of the risk
of severe infection.
"^ \/\ %o\> i •
A radiograph of the hand in the anteroposterior, lateral,
and oblique views should be done to check for debris that
may be embedded beneath the skin. Some glass is
radiopaque and will therefore be shown on the film.
However, some glass, wood, and plastic may not be
radiopaque and may not be seen on the film.
Associated fractures should be ruled out.
4
Fractures of the bones of the hand are classified by the
nature and site of the fracture line and whether the
fracture is closed or open (Fig. 34). An open fracture is one
that communicates with the skin wound.
Because of angular or rotational deformity, simple
inspection of the hand will often alert the examiner that
a bone or joint injury has occurred. It is important that
proper anteroposterior and true lateral radiographs be
obtained to confirm the presence of bony injury; the
amount of angulation of the fracture may not be appreciated on improperly positioned views. A careful physical
examination is essential to evaluate rotational alignment.
Since the flexed fingers normally point toward the
tubercle,of the scaphoid, malrotation is best evaluated by
observing the fingers in tins position. The rotational
alignment of the involved finger can also be compared
with that of adjacent uninjured fingers by noting if the
planes of the distal fingernails are parallel.
It is important to realize that the deformity of fractures
in the hand is due not only to the mechanism of injury but
also to the deforming forces ot the musculotendinous
units acting across the fracture site (Fig. 35).
' 63
»
6c
FRACTURES AND DISLOCATIONS 65
T
COMMON
64 THE HAND'
Closed
Open
Midshaft
E
*
Base
3
c
^
2
>
Dorsal
angulation
Volar
angulation
Neck
Comminuted ) Hj&&
Kgure 34
Fracture terminology
l L
Spiral
Figure 35
Deforming force acting on fracture site (A) The intrinsics flex the
proximal fragment of the proximal phalanx; the intrinsic flexor
and extensor with longitudinal pull cause further buckling at the
fracture site (B) The intrinsic muscle cuses flexion deformity of
metacarpal fracture.
COMMON FRACTURES AND DISLOCATIONS 67
It is apparent from the following examples that a
knowledge of the functional anatomy of the soft tissues
related to the joints of the hand is essential to understanding these potentially disabling injuries. The radiographs can misleadingly suggest that a very simple
fracture has occurred with only a small fragment of the
bone involved. This fragment, however, is often the major
attachment of a collateral ligament, the volar plate, or a
tendon. This small fracture may render the joint grossly
or potentially unstable. Since many of these articular
fractures were actually dislocations at the time of injury,
the x-ray film may not indicate the true degree of original
displacement that occurred.
INTRA-ARTICULAR FRACTURES
Particular attention should be directed to intra-articular
fractures around the PIP joint (Fig. 36). These often
involve injuries t o j h n vnlsr plate and portions of the
collateral ligaments. The early objective evidence oTthTs
may be seen radiographically as small, avulsed fragments
of bone around the joint. When a volar triangular fracture
fragment from the middle phalanx involves more than
one quarter of the articular surface, dorsal dislocation of
the middle phalanx may occur late because the volar plate
and a significant portion of the collateral ligaments are
attached to this small fragment. Because of this instability, these fractures often require surgical treatment.
Early recognition and proper treatment depend on an
awareness of the importance of these initial radiographic
findings. Undertreatment is a common cause of disability.
Unstable fracture-dislocation of PIP joint with volar fragment;
radiographic appearance above; ligament attachments, below
COMMON FRACTURES AND DISLOCATIONS 69
BENNETT'S FRACTURE
Bennett's fracture is an oblique intra-articular fracture
from the ulnar base of the thumb metacarpal (Fig. 37). The
palmar-ulnar portion of the metacarpal, which with its
heavy ligamentous attachments normally stabilizes this
joint, is separated from the larger distal fragment which
is displaced by the pull of the APL.
FIFTH CMC FRACTURE-DISLOCATION
As in the thumb, an intra-articular fracture involving the
palmar articular surface of the base of the fifth metacarpal
may be unstable. This occurs as a result of the joint's
relative mobility and the proximal pull of the ECU, which
inserts onto the dorso-ulnar base of the fifth metacarpal.
BOXER'S FRACTURE
"Boxer's fracture" usually involves the acute angulation
of the head of the metacarpal of the small Tinger into the
palfnraSThe result of a blow on the distal-dors~at*aspect of
the closed fist. A loss of prominence of the metacarpal
head is often seen on physical examination. The active
motion of the small finger may be minimally disturbed on
initial examination.
F R A C T U R E O F T H E S C A P H O ID
The bone most commonly fractured in the wrist is the
scaphoid. There is tenderness on deep palpation in the
snuff box area of the wrist just distal to the radial styloid
70
THE HAND
COMMON FRACTURES AND DISLOCATIONS 71
(Fig. 38). An oblique radiograph (scaphoid view) will
usually best show the fracture. Frequently the initial
radiograph will fail to show the fracture, whereas repeat
views of the scaphoid taken 2 weeks later mayHsEow it
arter there has been resorption ot bone at the fracture, site.
In alHvi'lyt Injuries with snuri box tenaerness, careful
evaluation with adequate follow-up is required to make
certain that these occult fractures are not overlooked.
Barlii-m^ljrfa j m ^ n g is an extremely effective-means
of confirming or ruling out the presence of a scaphoid
fracture. The test can be performed as early as 24 hours
after injury.
(JjiAfcS. (DX-tLfti \xX*TTHE MCP JOINT DISLOCATION
^—
The thumb may be subjected to significant hyperextension forces. The MCP volar plate may be disrupted at its
metacarpal attachment with a hyperextension injury, and
the joint may dislocate so that the proximal phalanx
comes t o ' l i e dorsal to the metacarpal head which
buttonholes between the intrinsic muscles and the FPL.
Similarly, the finger MCP joint (most commonly index
or small) may dislocate, with the metacarpal head becoming entrapped between the flexor tendon ulnarly, the
lumbrical musculotendinous unit radially, and the volar
plate dorsally.
These dislocations can only be detected on true lateral
radiographs and almost always require open reduction.
e
«ondeep p a ] p a t i o n .
TORN ULNAR COLLATERAL LIGAMENT OF
THE MCP JOINT O F THE THUMB
Acute radial deviation of the thumb at the MCP joint may
disrupt the ulnar collateral ligament. It is commonly
L
G4wK-it^P
COMMON F ^ E S A ^ S L O C ^ O N S "
COMMUN r i\™_ .
, . i_ i.v.a tVmmb is
caused by falls_whilR gVjvng, in which the thumb is
fdrcetully radially deviated by the ski pole or strap when
the hand hits the ground. It is important to compare the
joint stability of the injured thumb with the patient's
uninjured thumb. The lateral stress should be applied
with the MCP joint in lSnETTTr^tttexlon and in full
flexion. This test can be done clinically or under radiographic control. If the radial deviation of the thumb on
stress testing with local wrist block anesthesia is 15°
greater than that of the uninjured thumb, the collateral
ligament is probably disrupted. Surgical repair is usually
advisable (Fig. 39).
Figure 39
Rupture of ulnar collateral ligament of the MCP joint of the thumb
5
ACQUIRED
DEFORMITIES
Deformities of the hand may be congenital or acquired.
The acquired deformities may be associated with previous traumatic injuries to joints, tendons, or nerves, with
progressively contracting fascia of the palm, or with
arthritis. A discussion of some of the common deformities
is presented.
MALLET FINGER
The mallet finger is a flexion posture or "droop" of the
finger at the DIP joint area in which there is complete
passive but incomplete active extension of the DIP joint
(Fig. 40). The cause of the injury is usually a sudden blow
to the tip of the extended finger. The jnsertinn_of l .the
extensor tendon may be avulsed. or there may be an
avulsion fracture of the distal phalanx with a dorsal piece
of bone still attached to the extensor tendon. The PIP joint
should always be examined to rule out co-existing injury.
Anteroposterior and true lateral radiographs of the PD?
and DIP joints are part of the examination. A laceration
over the dorsum of the distal joint may sever the extensor
tendon and result in a mallet finger deformity.
75
ACQUIRED DEFORMITIES 77
76 THE HAND
figure 41
Boutonni&re deformity
Figure 40
Malletfingerdeformity (with or without fracture)
ACQUIRED DEFORMITIES 79
78 THE HAND
BOUTONNTERE DEFORMITY
In boutonniere deformity of the finger there is flexion of
thePIP inint and hyperextension of the DIP joint (Fig. 41).
It is the result of an injury or disease disrupting the
extensor tendon insertion into the dorsal base of the
middle phalanx. The fibers maintaining the position of
the lateral bands progressively tear or stretch, allowing
the lateral bands to slip volar to the axis of the PIP joint,
with the result that they become flexors of the PIP. The
deformity may not be present, however, immediately
following the injury, but can develop over several days or
weeks as the lateral bands drift progressively volarward.
SWAN-NECK DEFORMITY
j$frt &
This deformity of the finger is one in which the PIP jnint
is in hyperextension with the DIP joint in flexion (Fig. 42).
It can be yeeii hi 'A variety ot conditions such as
rheumatoid arthritis^certain types of spasticity, PlP joint
volar plate injury, or old mallet linger deformity.
CLAWHAND
Claw hand deformity is manifest by flattening of the
transverse metacarpal arch and longitudinal arches, with
hyperextension of the MCP joints and flexion of the PEP
and DIP joints (Figs. 28 and 43). The deformity is
produced by an imbalance of the intrinsic and extrinsic
muscles. The jntrinnignnsnips roust be markedly weakened or paralyzedAThe long extensor muscles ~Evperextend the MCP joint, and the long flexor muscles flex the
PIP and DIP joints. Loss of intrinsic muscle function is
L
Swan-neck
Figure 42
deformity
sometimes referred to as an "intrinsic minus hand." This
deformity can be seen in such anomalies as ulnar nerve
lesions, combined median and ulnar nerve lesions,
brachial"pfr icwt ~' 33 i"r ifiS r "p""*1 ^nrdjnjuries, and Charcot-Marie-Tooth disease.
DUPUYTREN'S C O N T R A C T U R E
Dupuytren's contracture is a confracture^aL-Uje, proliferated longitudinal hands nf the~palmar aponeurosis
lying betweSn~tfre~9k4n- alUl iltSX6r tendons in the distal
palm and fingers (Fig. 44). The flexor tendons are not
involved. It occurs most often in the ring and small
fingers. It begins as a nodule and progresses to fibrous
bands, with contracture of the fingers. It is usually not
painful and is most often seen in older men. It is often
familial
^ S ^ O A w f V ^ M
RHEUMATOID ARTHRITIS
Figure 43
Claw hand deformity associated with (A) ulnar nerve palsy and
(B) combined median and ulnar nerve palsy
iV_
Rheumatoid arthritis in the hand usually starts with stiff,
swollen, painful fingers. The MCP and PIP joints are the
ones most frequently involved. Stiffness and pain are
worse on arising in the morning. As the disease progresses, the digits often become deformed and the classic
ulnar drift deformity of the fingers may develop (Fig. 45).
Swan-neck and boutonniere deformities are common.
CarpaTtunnel syndrome, trigger finger, wrist tenosynovitis, painful flexor tenosynovitis, and rupture of tendons
may be present.
I
ACQUIRED DEFORMITIES 83
82 THE HAND
Figure 45
Figure 44
Dupuytren's contracture
/ ^
ACQUIRED DEFORMITIES 85
Figure 46
^eneraUvea r t h r i t J s o f t h e h a n d
Figure 47
(A) Axial compression-adduction test (B) Axial compression and rotation test
ACQUIRED DEFORMITIES 87
86 THE HAND
DEGENERATIVE ARTHRITIS
In degenerative arthritis (osteoarthritis) of the hand, the
distal joints develop marginal osteophytes known as
Heberden's nodes (Fig. 4fil. Similar bony lesions, called
^mirhp^'n n H e s . may occur at the_PIP joint. The MCP
joints are seldom involved.
The CMC joint of the thumb is also a common site for
degenerative arthritis in the hand. The axial compressionadduction test (Fig. 47) is done by manipulating t h e
thumb with axial compression and gentle adduction. The
instability and crepitus are appreciated with the examining thumb placed on the joint and base of metacarpal.
This is usually painful for the patient with joint involvement. The axial compression and rotation (Fig. 47) are
often painful when the proximal phalanx is used as a
lever arm for a grinding maneuver of the thumb CMC
joint.
DEQUERVAIN'S TENOSYNOVITIS
&%\<^
A nonspecific tenosynovitis of the^Ppand^jgPB^tendons
in the first_dbrsaL-wrist compartment is known as
<^3eQuervain's disorders-Tenderness and crepitation may
~be presentover the radial styloid. Finlrftlfjfftjn'g test may
be positive (Fig. 48). It is performed by having the patient
grasp the thumb with the fingers (thumb in palm) and
ulnar deviate the wrist. If this causes pain the test is
positive.
It is important to differentiate between deQuervain's
tenosynovitis and CMC joint arthrosis of the thumb. To do
this, tenderness and pain must be accurately localized
between this first extensor compartment and the CMC
joint of the thumb. Radiographs should be taken if there
is uncertainty.
Figure 4S
for deQuervain's d i ^ e
ACQUIRED DEFORMITIES 89
TRIGGER THUMB AND TRIGGER FINGER
Stenosing tenosynovitis can occur in the thumb or any
finger, but it most commonly occurs in the ring or middle
fingers. Inflammation at the MCP joint pulley causes a
discrepancy between the size of the tendon and pulley.
The tendon may become thickened just proximal to the
pulley. This discrepancy in size may cause a snapping or
locking phenomenon, holding the thumb or finger flexed
or extended (Fig. 49). Palpation of the flexor tendon over
the MCP joint can be painfull '
"
CARPAL TUNNEL SYNDROME
The carpal tunnel syndrome is a median nerve compression neuropathy at the wrist where the nerve passes
beneath the transverse carpal ligament (Fig. 50). Patients
complain of their hands "going to sleep" and are frequently awakened at night with numbness, pain, and
tingling in the thumb, index, long, and ring fingers. The
small finger is not usually involved. Patients may complainof referred pain in the forearm and even as high as
thfiTsEbuidec, They notice these symptoms when driving
a car or during other sustained activities. The entity is
more common in women than men. The dominant hand
is more often involved but symptoms can be bilateral. The
carpal tunnel syndrome may be associated with rheumatoid arthritis or following a TpMftg' fra^tur-p it can also be
seen in a variety of medical conditions such as pregnancy,
diabetes meliitus. and thyroid disease. However, most
patients with the carpal tunnel syndrome have no
apparent associated systemic disease.
ACQUIRED DEFORMITIES 91
The hand will most often look normal; however, in
long-standing cases there may be atrophy of the median
innervated thenar muscles (Fig. 51).
Tapping over the median nerve at the wrist crease may
produce paresthesias in the hand'tTmel's signj^JFig. 52).
The wrist flexion test (Phalen's test) (FigT'53fIs done by
resting the elbows on a table and allowing the wrists to fall
into complete volar flexion for 1 minute. If the patient has
carpal tunnel syndrome, this position may produce
paresthesias in the hand. If the patient is unable to flex the
wrist as a result of pain or limited motion, direct
compression of the median nerve can be accomplished by
applying pressure with the thumb in the interval between
the PL and FCR tendons at the level of the distal wrist
flexion crease for 1 to 2 minutes duration. The development of discomfort or paresthesias in the distribution of
the median nerve or an asymmetry in onset of symptoms
when compared with the opposite wrist suggests possible
carpal tunnel syndrome.
CUBITAL TUNNEL SYNDROME ^ o W wu*
e s ^ ^
Numbness nr paresthesias in the ring^ and small fingers of
the hand suggests the possibility of entrapment neuropathy of the ulnar nerve. The ulnar nerve is susceptible
to compression in the cubital tunnel at the elbow and^,
, Guyon's canal at the wrist. The cubital tunnel is the
fibro-osseous canal, which stabilizes the ulnar nerve as it
passes behind the medial epicondyle of the humerus.
There are multiple causes for injury to the ulnar nerve at
this location including hypermobility or subluxation of
the nerve from the cubital tunnel, and changes in the
anatomic alignment of the elbow. Compression injury of
the ulnar nerve within the cubital tunnel can be identified
j
if
ACQUIRED DEFORMITIES 93
92 THE HAND
Figure 52
Tinel's sign
Figure 51
Atrophy of the thenar muscle
l
94
'
THE HAND
ACQUIRED DEFORMITIES 95
by a painful Tinel's sign and the onset of paresthesias in
the ring and small fingers with elbow flexion under 2
minutes. With entrapment of the ulnar nerve at the
cubital tunnel, there may be numbness over the dorsoulnar aspect of the hand in addition to paresthesias in the
ring and small fingers. In more severe cases of cubital
tunnel syndrome, there will be decreased 2PD in the
sensory distribution of the ulnar nerve as well as muscle
weakness and/or wasting of the intrinsic muscles innervated by the ulnar nerve. Clinical findings include a
P"_citiyft Frrnnfint'Q tpct, wasting of the first dorsal interosseous muscle, inability to cross the index and middle
fingers, and clawing of the ring and small fingers.
Entrapment of the ulnar nerve at the wrist may
demonstrate a positive Tinel's sign on percussion over the
ulnar nerve at Guyon'sj-.anaV and"a positive Phalen's test
with parestEesiaTin the ring and small fingers. It will not
demonstrate loss of sensation over the dorso-ulnar aspect
of the hand. Depending on the site and severity of
compression, there may be diminished 2PD and/or ulnar
intrinsic muscle weakness.
^ £/v **
e^
> v
LATERAL EPICONDYLITIS - " f c ^
^ ^
~* 6 t e 6
Although sometimes referred to as tennis elbow, this
condition most commonly develops in individuals who
perform repetitive manual labor. The injury appears to
involve a detachment of the origin of the ECRB fromjhe
lateral epicondyle. THe injuryiraggravated*b"y lifting with
the lorearm in a position of pronation and the wrist held
in extension. Examination demonstrates point tenderness
over the lateraljepiconayie. t h e patient's pain can be
reproduced by having thepatient extend the wrist against
resistance with the elbow held in extension and the
forearm in pronation.
Figure 53
s«gn (wristflexiontest)
Phalen,
.k
I
/.
6
CONGENITAL
ANOMALIES
Congenital defects are often encountered in the examination of the hand. These defects should be recorded in an
accurate and complete manner. In the past, the use of
various Greek and Latin names to describe common
deficiencies has only served to confuse many clinicians.
A classification should be used that groups cases according to the parts that have been affected primarily by
certain embryologic failures.
The various clinical pictures of limb deficiencies are
felt to represent varying degrees of destruction within the
ectomesenchymal mass that develops on the lateral body
wall of the developing embryo. The limb bud is first noted
at the fourth week after gestation. These buds grow and
differentiate rapidly in a proximodistal sequence during
the following four weeks. Any factor, environmental or
otherwise, that disrupts the sequential differentiation
during this period will produce a defect in the limb
compatible with the timing of the insult.
Congenital defects should be classified in the following
categories as outlined by the American Society for
Surgery of the Hand and the International Federation of
Societies for Surgery of the Hand:
97
CONGENITAL ANOMALIES 99
98 THE HAND
J
/1
1.
2.
3.
4.
5.
6.
7.
The deficiencies in the group reflect the separation of the
pre-axial (radial) and post-axial (ulnar) divisions in the
limb and include longitudinal failure of formation of the
entire limb segment (phocomelias) of either radial, central, or ulnar components of the limb.
An example of a segmental failure would be the
phocomelia (hand attached to the trunk). This would be
classified: longitudinal (L), left or right (L-R), humerus
(Hu), radius (Ra), ulna (Ul).
The absence of parts of the radial (pre-axial) side of the
limb may vary from deficient thenar muscles to a short
floating thumb, and from deficient carpals, metacarpals,
and radius to the classified so-called radial club hand.
The classification of longitudinal, right, radius, proximal
one third, carpal partial, first ray, would be a deficiency
with a partial absence of the radius and carpal bones with
no thumb on the right.
Central deficiencies include deficiencies of the middle
three digits: index, long, and ring, and sometimes the
carpal bones. The middle digit may be missing in the
so-called lobster claw hand.
In ulnar deficiencies, the small or ring finger may be
missing and can be associated with partial or complete
absence of the ulna and carpal bones. These are classified
in a like manner.
FAILURE OF DIFFERENTIATION
(SEPARATION) OF PARTS
Failure of formation of parts (arrest of development).
Failure of differentiation (separation) of parts.
Duplication.
Overgrowth (gigantism).
Undergrowth (hypoplasia).
Congenital constriction band syndrome.
Generalized skeletal abnormalities.
FAILURE O F FORMATION OF PARTS
The category of failure of formation of parts is that group
of congenital deficiencies noted by failure or arrest of
formation of the limb either complete or partial. This
category is divided into two types: transverse and longitudinal.
Transverse deficiencies
Transverse deficiencies represent the so-called congenital amputations ranging from aphalangia (absence of the
fingers) to amelia (absence of the extremity). The stumps
are usually well-padded and may show rudimentary
digits or dimpling. One of the most common defects in the
group is the short below elbow amputation. This would
be classified as a transverse (T), left or right (L-R), forearm
(FO), upper one third deficiency.
Failure of differentiation is that category in which the
basic units have developed but the final form is not
completed. The homogenous anlage divides into separate
tissues of skeletal, dermomyofascial, or neurovascular
elements found in normal limbs, but fails to differentiate
Longitudinal deficiencies
Longitudinal deficiencies include all other limb deficiencies in this category. In identifying longitudinal deficiencies, all completely or partially absent bones are named.
i&
A
100 THE HAND
completely or to separate. An example in the forearm
would be a synostosis (fusion of bones which are
normally sflpara W ) nf the proximal radius and ulna. In
the wrist, fusion of carpal bones is frequently seen as well
as fusion of two or more metacarpals. Symphalangism is
. end-to-end fusion of the proxiaaal-mierphalflTigpal jnjnta
"^Syndactyly is by far the most common deformity seen in
this category. The failure of differentiation can vary from
simple skin bridging to fusion of parts.
Contractures secondary to failure of differentiation of
muscle, ligaments, and capsular structure are frequently
seen. They vary from simple trigger thumb to flexion
contractures of the small finger (camptodactyly) to the
severe arthrogryposis of the hand.
"*"
Lateral deviation or displacement due to asymmetrical
abnormalities of the digits (clmodactyly) also occurs.
DUPLICATION
Duplication of parts probably occurs as a result of a
particular insult to the limb bud and ectodermal cap at a
very early stage of their development so that splitting of
the original embryonic part occurs. These defects may
range from Polydactyly (too many digits) to twinning or
mirror hand (duplication of the digits present). They are
classified according to the parts or tissues duplicated.
Polydactyly is the most common deformity seen in this
group. It can be either radial (duplication of the thumb,
partial or complete), central (middle three fingers) or
ulnar (small finger duplication, partial or complete). The
fhumrj and small finger duplications are seen more
frequently.
CONGENITAL ANOMALIES 101
OVERGROWTH (GIGANTISM)
In this category, there can be overgrowth of the entire
limb or a single part." Some cases appear to be due to
skeletal overgrowth with normal-appearing soft tissue.
Others show excess fat, lymphatic, and fibrous tissue;
neurofibromata, lymphangiomata, or angiomata may be
present in these cases. A frequently seen deformity in this
category is gigantism of the digit and there can be an
accompanying syndactyly. This would be classified as an
overgrowth (gigantism) of the digit with syndactyly as a
secondary condition.
UNDERGROWTH (HYPOPLASIA)
Undergrowth or hypoplasia denotes defective or incomplete development of the parts. This may be manifested
in the entire extremity or its divisions. Hypoplasia may
involve any of the following systems: skin and nails,
musculotendinous, neurovascular, or the extremity (arm,
forearm, hand). An abnormally short, completely formed
metacarpal would be brachymetacarpia. Brachyphalangia refers to abnormally short middle phalanges.
CONGENITAL CONSTRICTION BAND
SYNDROME
This abnormality involves a circumferential constriction
of soft tissues of the extremity. Whether this is a
rifiVfllnpmRntal riftfer.t nr mqrhanjflal rnns^rjrtirin corondary to aminiotic bands remains uncertain. Compro-
102 THE HAND
mise in the development of the soft tissues distal to the
site of constriction may be associated with soft tissue
fusion of the distal parts, or may produce actual amputation. Those cases producing vascular compromise require
surgery to maintain the viability of the affected part.
7
TUMORS
GENERALIZED SKELETAL ABNORMALITIES
(MADELUNG'S DEFORMITY)
This congenital anomaly involves a hypoplasiaof the
cHsfaTulmtund ulnar aspect of the distal radius. Itls mbre
common in lemafeS than malesand is typically bilateral.
The deformity may not become detectable until the child
reaches adolescence. A similar deformity can sometimes
be produced by infection or trauma.
The most common soft, tissue mass of the hand is a
^ganglToiaijtFlM. 34). It has a well-denned, smooth"surface
and is a firm cystic lesion that is fixed to the deep tissues.
It may develop over the volar or dorsal area of the wrist,
originating from the wrist capsule. Those in the palmriear
the digital palmar skin crease arise from the flexor tendon
sheatixand may or mav not be painful.
Al rniir.nus cyst^js acystic lesion (actually a ganglion)
o v e r t h e dorsum of the finger near the distal joint and
fingernail (Fig. 55). It is associated with degenerative
ajtEitiTbf, the T)fP joint of the finger and arises from the
joint. It may have thin walls and there may be associated
grooving of the fingernail distal to the cyst. Should a
mucous cyst rupture and become infected, a septic joint
may result.
Other soft tissue tumors of the hand that may present
as a mass are giant cell tumors of tendon sheath,
pigmented villonodular synovitis, and inclusion cysts.
Malignant tumors of the soft tissue and bone are rare in
the hand. However, skin cancers (basal cell and squamous cell) on the dorsum of the hand are seen in the
elderly. Malignant melanoma does occur in the hand and
may be subungual^—IS**? KAM-ofc*/
103
iti
TUMORS 105
104 THE HAND
Figure 55
Mucous cyst
Figure 54
Ganglion of the hand
k
J
106 THE HAND
Primary bone tumors of the hand usually present as
swelling and/or pain in the area of the hand involved. The
tumor is located radiographically and the diagnosis is
established by biopsy of the tumor. The most common
\L \ bone tumor of the hand is ap/epr:hop(jrnTp^lt is often first
ri J Tfiscovered when a fracture "ormirs throT^h thp Ipsipn^
8
INFECTION
PARONYCHIA
A paronychia is an infection of the soft tissue around the
fingernail that usually begins as a "hanHnajl" and that is
usually caused by arstaphylococcus jni'ection (Fig. 56A).
It sgreads^ around thiT nailTepohychium, thus the term
"run around." It is red, swollen, and very painful, with
purulent drainage around the margin of the nail.
FELON
A felon is a deep infection of the pulp space of the distal
segment of the finger (FigT'gSBjrThg^distal segment is
swollen, red, and extremely painful. Drainage ^js usually
required. It is usually caused by a staphylococcus infection and can involve the distal phalanx with osteomyelitis.
PURULENT TENOSYNOVITIS
Infection of the tendon sheath of the digit presents as a
swollen, slightly flexed finger with tenderness over the
107
I
108 THE HAND
INFECTION 109
flexor tendon sheath and increased pain on passive
extension of the digit (Fig. 56C). These findings constitute
if- Kanavel's four cardinal signs of a purulent tendon sheath
Infection.
"TFthe tendon sheath of the small finger or thumb is
involved primarily, the infection may spread to the wrist
area where the sheaths communicate and the classic
"horseshoe" infection may develop (Fig. 57). The sheath
of the index, long, and ring fingers extends to the palm but
/•«
not to the wrist. Streptococcus and staphylococcus are ,f]AA^
the most frequent infecting organisms. «=— $MVA*T- jof^'
|
These are serious infections which may extend along
the flexor tendon sheath, and prompt treatment is most
important.
SPACE INFECTIONS
g o a l ' s /a«£ cardinal signs of
flexor tendon sheath infection:
1
s
Mliflexign
2. Swelling
3- Tenderness over &qorJmuim sheath
4. Pain on_passive extension
Figure 56
(A) Paronychia (B) Felon (CJ Flexor tendon sheath infection
Thenar space and mid-palm infections are not common.
When they do occur the dorsum may be more swollen
than the palm of the hand. This should not mislead the
examiner. The usual findings of redness, tenderness, and
perhaps fluctuance help to define the abscess.
The thenar space is a potential space anterior to the
adductor muscle (Fig. 58). Its ulnar border is separated
from the mid-palm space by a fascia arising from the
metacarpal of the long finger and attaching to the palmar
fascia.
The mid-palm space is the potential space anterior to
the interosseous muscles and posterior to the flexor
tendons of the long, ring, and small fingers (Fig. 59).
HO THEHAND
INFECTION 111
Figure 57
Tendon sheaths of the flexor tendon
Figure 58
Thenar space infection of the hand
INFECTION 113
112 THE HAND
H U M A N BITE INFECTIONS
Human bites are commonly seen over the dorsum of the
MCP joints. These usually occur when the joint area
stances a toothj n a fight. The important point is that the
wound may appear benign initially, but is usually
inoculated with a potent mixture of bacterial flora. This
is a serious injury requiring prompt treatment^
:
Figure 59
Mid-palm space infection of the hand
L
/
APPENDIX
1
KEY T O A B B R E V I A T I O N S
IN THE
<•
ADM
AdP
APB
APL
CMC
DIP
ECRB
ECRL
ECU
EDC
EDM
EIP
EPB
EPL
FCR
FCU
FDM
FDP
FDS
FPB
FPL
I
IP
M
USED
TEXT
Abductor digiti minimi
Adductor pollicis
Abductor pollicis brevis
Abductor pollicis longus
Carpometacarpal
Distal interphalangeal
Extensor carpi radialis brevis
Extensor carpi radialis longus
Extensor carpi ulnaris
Extensor digitorum communis
Extensor digiti minimi
Extensor indicis proprius
Extensor pollicis brevis
Extensor pollicis longus
Flexor carpi radialis
Flexor carpi ulnaris
Flexor digiti minimi
Flexor digitorum profundus
Flexor digitorum superficialis
Flexor pollicis brevis
Flexor pollicis longus
Index finger
Interphalangeal
Middle finger
'
115
" 6 THE HAND
MCP
ODM
OP
PIP
PL
R
S
Metacarpophalangeal
Opponens digiti minimi
Opponens pollicis
Proximal interphalangeal
Palmaris longus
Ring finger
Small finger
APPENDIX
2
ANATOMY—SUMMARY
117
a
Extension-abduction
Thumb CMC
Flexion-adduction
Extension
Finger DIP
Flexion
Extension
Finger PIP
Flexion
EPL, EPB
APL
APB
AdP
Ulnar V« FPB
1st dorsal
interosseous
FPL
None
43
Median
Radial
Radial
Median
Ulnar
Ulnar or Median
9,11
15
Median, I. & M.; 6
Ulnar R. & S.
Ulnar
Median & Ulnar
Radial
Interosseous
Lumbrical
EDC, EIP, EDM
FDP
Median
FDS
Ulnar
-Volar.
Interosseous
=!\ —LB
..
16,17
Ulnar
Dorsal.'
Interosseous
Abduction
i
Adduction'
43
8,12, 32
Ulnar
Median I. &M.;
Ulnar R. & S.
8,10,13
Fig. No.f
Radial
EDC
EIP
Extension
Interosseous
Lumbrical
Radial
Ulnar
ECU
FCU
Ulnar deviation
Finger MCP
Flexion
Radial
Median
Radial
Median
Median
Ulnar
Nerve
ECRL
FCR
FCR
PL
FCU
ECRL
^EGRBj
Prime* Muscle
Radial deviation
Extension
Wrist
Flexion
Joint Control
Strong DIP extension
contingent upon active
PIP extension control
Must block FDP to
detect clinical absence
Intrinsic independent
of MCP position:
extrinsic only if MCP
joint flexed or at 0°
(i.e., not hyperextended)
Absence—MCP
extensor lag
Absence—claw hand
Absence—"wrist
drop" :
Absence—weak wrist
flexion present by
FDS, FDP
Comments
A
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11
9
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Weak IP extension
also by intrinsics
'
A composite motion
Comments
('achieves a given function but does not imply 'the strongest' acting across that joint)
(tin addition to Figs. 19, 20, 22)
Median
Radial
Thumb IP
Flexion
\ Extension
FPL
Radial
Median
Median
Ulnar
Radial
Median
Nerve
Extension
FPL
thenar intrinsic
i J muscles l
- (except-OP)]
EPL
Supination
Thumb MCP
Flexion
APB
Radial V» FPB
OP
Prime* Muscle
Opposition
(Pronation)
Joint Control
INICAL
APPENDIX 3 123
122 THE HAND
patient's side, the elbow flexed at 90°, and the forearm and
hand resting unsupported. Record and calculate posttreatment percentage relative to pre-treatment value as
well as to value from the contralateral hand. Note: This is
not a percentage of physical impairment or improvement
but 'merely anAndicatof" of_ improving-or_wbrsening^]
< condition?1
Pinch strength
Use a pinch dynamometer. Key.pinch.is'the'thum^jrto
radial_aspect'of middle-phalanx-of the iridexjfjngerarid is
the most, universal and preferred value. Record three
successive efforts and calculate percentage relative to pretreatment as well as contralateral hand values. Tip pinch
value (reverse key pinch —index tip to ulnar tip of thumb)
will be less powerful than key pinch. Same recordings as
for key pinch. Note: This is not a percentage of physical
impairment or improvement but merely an indicator of
improving or worsening condition.
MOTION
I '
Total active motion (TAM)
Sum of angles formed by MCP, PIP, and DIP joints in
maximum active flexion, i.e., fist position, minus total
extension deficity at the MCP, PIP, and DIP joints with
active finger extension. Significant hyperextension at any
joint, particularly the PIP and DIP joints, is recorded as a
deficit in extension and is included in the total extension
deficit. Hyperextension must be considered an abnormal
value in swan-neck, (PIP) and boutonniere deformities
(DIP). Comparison 6fpT^aTrdrpjSM^ea'tmentTAM.values
.will be significant; however, comparison as a percentage
of normal value is invalid.
TAM is a term applied to one finger, and is analagous
to TPM in calculation except that only active motion is
recorded, not passive.
1. Suni"ofTctive"MCP"flexion"'+ 'active PlP^flexion'^
active .DIP flexion.-}
2. Minus sum of"incomplete active extension (if any is
present).
It is of critical importance to emphasize that this system
of measuring and recording joint motions is used in the
following situations:
Total passive motion (TPM)
Sum of angles formed by MCP, PIP, and DIP joints in
maximum passive flexion minus the sum of angles of
deficit from complete extension at each of these three
joints: (MCP + PIP + DIP) - (MCP + PIP + DIP) = total
flexion - total extensor lag TPM.
1. For a single digit
2. To indicate the total motion of that digit in degrees
3. To compare this to subsequent measurements of
that same digit or the corresponding normal digit of
the opposite hand in the same patient to determine
if the patient is gaining or losing motion
APPENDIX 3 125
12 4
THE HAND
Stiff MCP + ,
limited PIP extension
*-.*
Stiff MCP + Limited PIP Extension
MCP
PIP
DIP
Totals
Af^Actlve Motion (TAM)
260° - 0" = 260°
Figure 60
&
Active
Flexion
Extension Lack
MCP
PIP
DIP
Totals
0°
90°
10°
100°
0°
30°
0°
30°
Total Active Motion (TAM)
100° - 30° = 70°
Figure 61
"W
APPENDIX 3 127
126 THE HAND
It is not intended for the following:
1. To calculate a percentage of "functional improvement or loss"
2. To calculate a "percentage of impairment"
Limited MCP + PIP flexion
with good extension
Note that some finger joints are more important than
others in digital function. Furthermore, note that "function and impairment" involve many other factors as well,
such as sensation.
VASCULAR STATUS
Patients who have vascular repair are evaluated in the
following manner (not acutely, but late):
1. Examine for tissue survival.^
. _. , _
2. Objective-evidence nf-patent vesselsJbv. Allen test
and^orliltfasonic^ulse-detector.
3. ReVascularizeTil^^xaminell in resting and postexercise state by one of several methods:
a. presence of capillary filling.
b. physiologic testing such as ultrasonic pulse
detector, skin temperatures, etc.
When possible, comparison with evaluation before
and after 3-minute tourniquet ischemia.
4. Evaluation regarding cold tolerance of the part.
Limited MCP + PIP Flexion with Good Extension
Active
Flexion
MCP
PIP
DIP
Totals
70°
60°
10°
140°
Extension Lack
Ratings
1. Failure, no survival.
2. Poor, tissue survival.
3. Fair, objective evidence of patent vessels.
4. Good, function not limited by circulation.
5. Excellent, no cold intolerance.
Total Active Motion (TAM)
140° - 0° = 140°
Figure 62
W
1
INDEX
Page numbers followed by f indicate figures.
Abbreviation key, 115-116
Abductor pollicis longus
(APL) testing, 211, 22
Allen test, 46f
Anatomic variation, and
nerve injury, 41
Anatomy, 47-56, 118-120
Anomalies, congenital, 97102
congenital constriction
band syndrome, 101102
differentiation of parts,
99-100
duplication of parts, 100
formation of parts, 98-99
overgrowth, 101
skeletal abnormalities,
102
undergrowth, 101
Arches of hand, 52f
Axial compressionadduction test, 85f
Axial compression and
rotation test, 85f
Basilar joint of thumb, 53f
Bennett's fracture, 68f, 69
' B ^
Bones, anatomy of, 7f, 4756
Boutonniere deformity, 77f,
78
Boxer's fracture, 69
Carpal tunnel syndrome, 89,
90f
Phalen's test for, 94f
thenar muscle atrophy,
92f
Tinel's sign, 93f
Carpus, anatomy of, 47-51
Circulation, 45-47, 46f
Claw hand, 78-81, 80f
Congenital constriction
hand syndrome, 101102
Cubital tunnel syndrome, 91
Deformities, acquired, 7595
boutonniere deformity,
77f, 78
carpal tunnel syndrome,
89, 90f
claw hand, 78-81, 80f
INDEX 135
134 INDEX
fifth dorsal wrist
Deformities (Continued)
compartment, 25, 26f
cubital tunnel syndrome,
first dorsal wrist
89, 90f
compartment, 21f, 22
degenerative arthritis, 84f,
fourth dorsal wrist
85f, 86
compartment, 22, 26f
deQuervain's
second dorsal wrist
tenosynovitis, 86, 87f
compartment, 22, 23f
Dupuytren's contracture,
sixth dorsal wrist.
compartment, 25, 27f
81, 82f
lateral epicondylitis, 95
tendon arrangement, 20f
mallet finger, 75, 76f
third dorsal wrist
rheumatoid arthritis, 81,
compartment, 22, 24f
Extensor pollicis brevis
83f
swan-neck deformity, 78,
(EPB) testing, 21f, 22
Extensor pollicis longus
79f
(EPL) testing, 22, 24f
trigger finger and thumb,
88f, 89
deQuervain's tenosynovitis,
86, 87f
Failure of differentiation,
Dislocations
99-100
fifth CMC, 69
Felon, 107, 108f
MCP joint, 71
Finger motion, lOf
Fingertip examination, 13,
Duplication of parts, 100
Dupuytren's contracture, 81,
14f
82f
Finkelstein's test, 86, 87f
Flexor carpi radialis (FCR)
muscle testing, 17
Flexor carpi ulnaris (FCU)
Epicondylitis, lateral, 95
muscle testing, 17
Extensor carpi radialis
Flexor digitorum profundus
brevis (ERCB) testing,
(FDP) muscle testing,
22, 23f
17, 18f
Extensor carpi radialis
Flexor digitorum
longus (ECRL) testing,
superficial (FDS)
22, 23f
muscle testing, 17,19f
Extensor carpi ulnaris (ECU)
Flexor muscle testing,
testing, 25, 27f
extrinsic, 15-17. See
Extensor digiti minimi
also specific muscle
testing, 25, 26f
Flexor pollicis longus (FPL)
Extensor digitorum
muscle testing, 16t, 17
communis (EDC)
Flexor tendon sheath
testing, 22, 26f
infection, 108f, HOf
Extensor indicis proprius
Forearm motion, lOf
(EIP) testing, 22, 25, 26f
Formational failures, 98-99
Extensor muscle testing,
longitudinal deficiencies,
extrinsic, 17-25
98-99
extrinsic extensor
transverse deficiencies, 98
tightness, 25
Fractures
Bennett's fracture, 68f, 69
Boxer's fracture, 69
deforming force, 65f
fifth CMC, 69
intra-articular fractures,
66f, 67
scaphoid, 69-71, 70f
terminology, 64f
Froment's sign, 29f
Ganglion of hand, 104f
Gigantism, 101
Guyon's canal, 39f
History, clinical, 5, 8
Hypoplasia, 101
Infection, 107-113
felon, 107, 108f
paronychia, 107, 108f
purulent tenosynovitis,
107-109, 108f, HOf
space infections, 109,
l l l f , 112f
Intra-articular fractures, 66f,
67
Intrinsic muscle testing, 2534
adductor pollicis muscle,
29f, 30
hypothenar muscles, 31,
33f
interosseous muscles, 3031, 32f
instrinsic muscle
tightness, 31, 34f
lumbrical muscles, 30-31
thenar muscles, 28f, 30
Joint anatomy, 7f, 47-56
Lacerations, 59-62
of EDC over MCP joint,
61f
examination, 60f
Ligaments, stabilizing, 48f,
50f
Madelung's deformity, 102
Mallet finger, 75, 76t
Median nerve, 35, 36f
sensory branches, 37, 42f
Mid-palm space infection,
112f
Motion
joint, terminology, lOf—
llf
total active motion, 123127
total passive motion, 122
Mucous cyst, 105f
Muscle examination, 15-34.
See also specific
muscle group
extrinsic muscles, 15-25
intrinsic muscles, 25-34
Nailbed complex
examination, 13-15,14f
Nerves, 35-45
anatomic variation, 41
median nerve, 35, 36f
radial nerve, 37, 40f
sensibility, 43, 45
sensory branches of, 37,
41
ulnar nerve, 35-37, 38f,
39f
Osteoarthritis, 84f, 85f, 86
Overgrowth, 101
Palmaris longus (PL) muscle
testing, 17
136 INDEX
Paronychia, 107, 108f
Phalen's test, 94f
Physical examination, 9, 12
anatomy of bones and
joints, 47-56
circulation, 45-47
fingertip and nailbed, 1315
muscles, 15-34
nerves, 35—45
skin, 13
Pulleys of digital flexor
sheath, 55f
Purulent tenosynovitis,
107-109, 108f, HOf
Radial nerve, 37, 40f
sensory branches, 41, 42f
Rheumatoid arthritis, 81,
83f
Scaphoid fracture, 69-71,
70f
Sensibility, 43-45, 121
two-point discrimination
testing, 44f
Sensory function, and
nerves, 37, 41, 42f
Skeletal abnormalities, 102
Skeleton of hand and wrist,
7f
Skin examination, 13
Space infections, 109, l l l f ,
112f
Strength, 121-122
grip strength, 121-122
pinch strength, 122
Surface anatomy, 6f
Swan-neck deformity, 78,
79f
Terminology, 8-9
Thenar muscle atrophy, 92f
Thenar space infection, 11 If
Thumb motion, llf
Thumb opposition test, 28f
Tinel's sign, 93f
Trigger thumb and finger,
88f, 89
Tumors, 103-106
ganglion, 104f
mucous cyst, 105f
Two-point discrimination
testing, 44f
Ulnar collateral ligament
rupture, 71-73, 72f
Ulnar nerve, 35, 37
muscles innervated by,
38f
sensory branches, 41, 42f
ulnar tunnel at wrist, 39f
Undergrowth, 101
Vascular assessment, 17
Wrist motion, lOf